What is the recommended evaluation and management for an adult male presenting with acute scrotal pain, swelling, and tenderness due to epididymitis‑orchitis?

Epididymitis-Orchitis: Evaluation and Management

Immediate Diagnostic Priority: Exclude Testicular Torsion

Before initiating any treatment, testicular torsion must be ruled out—this is a surgical emergency requiring immediate specialist consultation, particularly when pain onset is sudden and severe. 1

• Torsion occurs more frequently in patients without clinical evidence of inflammation or infection 1
• Emergency testing is indicated when pain onset is abrupt, severity is high, or initial examination does not confirm urethritis or urinary tract infection 1
• Testicular viability may be compromised within hours, making this the most critical differential diagnosis 1

Essential Diagnostic Evaluation

Obtain the following tests before starting antibiotics, but do not delay treatment while awaiting results:

• Urethral Gram stain (≥5 polymorphonuclear leukocytes per oil immersion field indicates urethritis) 1
• Nucleic acid amplification testing (NAAT) or culture from intra-urethral swab or first-void urine for N. gonorrhoeae and C. trachomatis 1
• First-void urine examination for leukocytes if urethral Gram stain is negative 1
• Urine culture and Gram stain of uncentrifuged urine to identify Gram-negative organisms 1
• Syphilis serology and HIV testing should be offered to all patients 1

Age-Based Antibiotic Treatment Algorithm

For Sexually Active Men < 35 Years

Administer ceftriaxone 250 mg IM as a single dose PLUS doxycycline 100 mg orally twice daily for 10 days. 1

• This regimen specifically targets C. trachomatis and N. gonorrhoeae, the predominant pathogens in this age group 1
• If intramuscular ceftriaxone is unavailable, substitute with cefixime 400 mg as a single oral dose (97.4% cure rate for gonococcal infection) plus doxycycline 1

Critical prescribing error to avoid: Do not use ciprofloxacin as first-line therapy in men < 35 years—it is not optimal for chlamydial infection 1

For Men ≥ 35 Years

Prescribe levofloxacin 500 mg orally once daily for 10 days OR ofloxacin 300 mg orally twice daily for 10 days. 1

• Enteric Gram-negative organisms, especially E. coli, predominate in this age group and are often associated with bladder outlet obstruction or urinary tract abnormalities 1
• Fluoroquinolone monotherapy is sufficient because sexually transmitted infections are less common 1
• Do NOT use the ceftriaxone + doxycycline combination in this age group 1

Important caveat: Rising ciprofloxacin resistance in E. coli isolates means levofloxacin or ofloxacin are preferred over ciprofloxacin 2

For Men Who Practice Insertive Anal Intercourse

Use ceftriaxone 250 mg IM single dose PLUS levofloxacin 500 mg orally once daily for 10 days (or ofloxacin 300 mg twice daily for 10 days). 3

• Enteric organisms are likely in addition to sexually transmitted pathogens in this population 3

For Patients with Cephalosporin or Tetracycline Allergy

Prescribe ofloxacin 300 mg orally twice daily for 10 days OR levofloxacin 500 mg orally once daily for 10 days. 1

• Ofloxacin achieves approximately 98.6% cure rate for gonococcal infection 1

Mandatory Adjunctive Supportive Care

All patients require bed rest, scrotal elevation, and analgesics until fever and local inflammation subside. 1

• Use a rolled towel or supportive underwear to elevate the scrotum 4
• Continue supportive measures throughout the acute inflammatory phase 1

Follow-Up Protocol and Red Flags

Reassess the patient within 3 days if there is no clinical improvement. 1

• Lack of improvement triggers re-evaluation of both diagnosis and antibiotic choice 1
• Consider admission for patients with severe pain suggesting alternative diagnoses (torsion, abscess, infarction), those who are febrile, or when outpatient compliance is uncertain 1

If symptoms persist after completing the 10-day antibiotic course, conduct comprehensive evaluation for:

• Testicular tumor 1
• Epididymal abscess 1
• Testicular infarction 1, 5
• Testicular cancer 1
• Tuberculous or fungal epididymitis 1

Emerging evidence: Funiculitis (inflammation of the spermatic cord) can co-exist with epididymitis and impede testicular blood flow, potentially leading to testicular necrosis requiring orchiectomy 5. Repeated Doppler ultrasonography may be necessary if clinical deterioration occurs despite appropriate antibiotics 5.

Sexual Partner Management

Refer all sexual partners from the preceding 60 days for evaluation and treatment if epididymitis is confirmed or suspected to be caused by N. gonorrhoeae or C. trachomatis. 1

• Patients must abstain from sexual intercourse until both they and all partners have completed therapy and are symptom-free 1
• Partners should be treated even if asymptomatic 4

Special Population Considerations

HIV-Positive Patients

HIV-infected patients with uncomplicated epididymitis should receive the same treatment regimens as HIV-negative patients. 1

• Fungi and mycobacteria are more likely etiologic agents in immunosuppressed patients 1

Elderly Patients with Underlying Urologic Abnormalities

Investigate bladder outlet obstruction from benign prostatic hyperplasia, urethral stricture, or recent urinary instrumentation (catheterization, cystoscopy, prostate biopsy) as predisposing factors. 1, 3

• These conditions increase risk of infection with enteric organisms through urinary reflux into the ejaculatory ducts 1

Common Pitfalls to Avoid

• Do not assume cure when pain improves—the full 10-day antibiotic course is required to prevent chronic complications and infertility 4, 3
• Do not use ciprofloxacin in men < 35 years as first-line therapy 1
• Do not delay torsion evaluation in any patient with acute scrotal pain, especially adolescents 1
• Do not permit premature resumption of sexual activity—this spreads infection and can worsen the condition 4